Provider Demographics
NPI:1104929165
Name:INIGO, MARICAR (NP)
Entity type:Individual
Prefix:
First Name:MARICAR
Middle Name:
Last Name:INIGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:243 GEORGIA STREET
Practice Address - Street 2:STE B
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-556-8100
Practice Address - Fax:707-556-8107
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15426363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-1915OtherFQHC MEDICARE PART A
CAHAP70543GOtherFPACT
CAFHC70543GMedicaid
CAZZZ23222ZOtherFQHC MEDICARE PART B